16: Defining Difficult Decisions and Out Points

Chapter 16 Defining Difficult Decisions and Out Points

Breast augmentation is a totally elective cosmetic surgical procedure. When a patient chooses to have a breast augmentation, the patient is choosing to place a medical device into the body—a device that is not medically necessary.

Each medical device has potential benefits, but every device also has potential risks, tradeoffs, and costs. Each medical device can potentially produce positive effects, but can also produce negative effects or undesired outcomes. Every patient who chooses to have breast augmentation should understand and accept that if certain problems or clinical situations arise, their surgeon will recommend removal of both implants without replacement. Every surgeon’s first responsibility is the welfare of the patient, not the implant, and implant removal without replacement is sometimes the best option to minimize additional reoperations, risks, costs, and chances of developing uncorrectable deformities.

Every surgeon’s first responsibility is the welfare of the patient, not the implant, and implant removal without replacement is sometimes the best option to minimize additional reoperations, risks, costs, and chances of developing uncorrectable deformities

Most patients, in the author’s practice experience, want to keep their implants regardless of the untoward events that occur. Most surgeons want to please their patients. Removing and not replacing breast implants is one of the most difficult decisions for surgeons and patients. Patients that are thoroughly informed preoperatively of specific events or conditions in which implant removal without replacement is in their best interests, and patients that document their acceptance of those conditions preoperatively are more likely to make the best decisions postoperatively. Explaining why implant removal without replacement is the safest and best option is exceedingly difficult postoperatively when the patient has not heard and acknowledged the explanation and reasons preoperatively.

Factors that Affect Responses to a Breast Implant

Every medical device implanted into the human body is placed in an environment where certain factors cannot be predicted or controlled by the surgeon or the patient, especially factors related to a patient’s individual wound healing characteristics and the genetic characteristics of each individual patient’s tissues.

Short- and long-term effects of a breast implant in the body depend on three different sets of factors: device related factors, surgically related factors, and patient wound healing and genetic tissue characteristics factors

A breast implant has a range of effects when placed into the body, effects that continue for the entire time the device is implanted. Short- and long-term effects of a breast implant in the body depend on three different sets of factors: device related factors, surgically related factors, and patient wound healing and genetic tissue characteristic factors. Surgeons and patients have some level of control over device related and surgically related factors, including selection of the type and size of implant, decisions to maximize soft tissue coverage over the implant, and optimizing surgical techniques to minimize tissue trauma and bleeding. Neither surgeons nor patients, however, can predict or control patient wound healing and genetic tissue characteristic factors. Table 16-1 summarizes factors that determine the effects of a breast implant in the body.

Table 16-1 Factors that determine the effects of a breast implant in the body

Implant device related factors	Surgical decision and technique related factors	Patient wound healing and genetic tissue characteristic factors
Implant size	Patient requests and patient’s ability to reconcile wishes with tissue characteristics	Tendency to develop thicker, tighter capsule around implant
Implant shape and projection	Implant size	Tendency to produce more fluid around implant
Implant filler material	Implant match to tissue characteristics	Quantity and types of bacteria in breast tissue
Implant shell characteristics	Implant projection and shape	Body ability to resist infection
Implant shell durability	Implant fill volume	Ability of tissues to support implant weight
Implant fill volume	Degree of soft tissue coverage	Ability of tissues to tolerate implant weight and projection without excessive stretch or soft tissue atrophy
Other implant design factors	Implant pocket location Degree of surgical tissue trauma Amount of bleeding Patient compliance with instructions	Tissue response to previous pregnancies and nursing

When surgeons and patients prioritize wishes over the realities and limitations of an individual patient’s tissues, compromised outcomes and negative tissue compromises over time are likely

When surgeons and patients prioritize wishes over the realities and limitations of an individual patient’s tissues, compromised outcomes and negative tissue compromises over time are more likely to occur. Surgeons and patients can impact device related factors by choosing implants based on their proved track record and data in Food and Drug Administration (FDA) studies and peer reviewed and published data in indexed medical journals instead of choosing implants based on subjective preferences or marketing hype. Surgeons can definitely impact surgically related factors by implementing quantitative tissue assessment and proved processes for implant selection, by optimizing surgical processes and efficiency that are proved in peer reviewed and published studies, and by implementing techniques that preclude the necessity of unnecessary postoperative adjuncts. Surgeons and patients cannot, however, significantly impact certain wound healing and genetic tissue characteristic factors that can affect outcomes.

Factors that no Surgeon or Patient can Predict or Control

No surgeon and no patient can predict or control a patient’s wound healing characteristics or a patient’s genetic tissue characteristics that can affect outcomes following breast augmentation

No surgeon and no patient can predict or control a patient’s wound healing characteristics or a patient’s genetic tissue characteristics that can affect outcomes following breast augmentation. Each patient has unique, individual wound healing characteristics and unique, genetic tissue characteristics that influence the interaction between a breast implant and the surrounding tissues. Individual wound healing characteristics influence the characteristics of the capsule or lining that forms around every breast implant, and affect the degree to which that capsule tightens or contracts which in turn determines whether capsular contracture will cause excessive firmness of the breast or other deformities. Patient wound healing characteristics may also affect the quality of incision scars, risks of infection or fluid production around an implant, and other factors that can affect the aesthetic result. Genetic and hormonal effects of pregnancy and nursing vary from patient to patient, and can affect aesthetic results and outcomes.

A patient’s genetically determined tissue characteristics can affect the response of the patient’s tissue to the implant, including how much the skin will stretch and thin in response to a specific size implant, and how the breast tissue overlying the implant will respond

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Tags: Augmentation Mammaplasty Redefining the Patient and Surgeon Expe

Jul 23, 2016 | Posted by admin in Aesthetic plastic surgery | Comments Off

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